Flexion-distraction Fracture at T12-L1: Brace or Surgery?
A 17-year-old female presents post-MVA. She was a rear seat belted passenger. She had isolated trauma to her back. She presents with back pain without any neurologic dysfunction. She has no past medical history, and she’s on birth control pills.
Clinically, she had tenderness with palpable gap at thoracolumbar junction with local bruising.
Neurologic exam was normal.
She had extensive abdominal swelling. She underwent a full work-up from general surgery and was cleared for any significant bowel trauma.
There was no prior treatment.
Figure 1: AP shows trauma at L1 with significant gapping of the posterior elements and fracture through the left pedicle and subluxation of the right T12-L1 facet joint. There’s extensive dilatation of the intestines.
Figure 2: Lateral x-ray shows kyphotic deformity at T12-L1 with significant gapping of the posterior elements. There’s a small compression fracture of L1 without any translational deformity.
Figure 3: Coned down AP x-ray
Figure 4: Coned down lateral x-ray
Figures 5A and 5B are coronal CT reconstructions showing gapping of the right disc space with fracture extending into the left L1 body. D shows dislocation of the right T12-L1 facet joint with a left-sided pedicle and transverse process fracture.
Figures 6A, 6B, and 6C are sagittal CT reconstructions showing the bony Chance fracture through the left pedicle and body with compression of the anterior column. Right side shows dislocation of the T12-L1 facet joint with disruption of the right-sided disc. Midline shows significant gapping of the posterior elements with fracture extending into the middle and anterior column.
Flexion-distraction fracture at T12-L1
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After recommending surgical treatment, the family declined and elected for brace treatment. X-rays (Figure 7) show patient stable in brace 4 weeks after the accident.
The family returned in close follow-up and proceeded with surgical treatment.
We did a single-level fusion utilizing intact pedicles for reduction on the right side and requiring a hook at L1 on the left side because of the pedicle fracture. Decompression was performed at T12-L1 prior to reduction. We were able to achieve excellent fixation intraoperatively and felt the single-level fixation was adequate for this young patient with good bone.
Figure 8: AP x-ray 1-week after surgery
Figure 9: Lateral x-ray 1-week after surgery
She’s now 5 years post-op and she’s doing well.
This is a classic flexion distraction fracture. The patient has approximately a 32 degree kyphosis with full disruption of the posterior tension band (interspinous, supraspinous, capsular complex) with associated facet fracture. Looking at the coronal CT reconstruction view, it is apparent that the injury disrupted the left side of the disc itself before the energy of the injury entered the L1 vertebra body on the right and fractured the lateral wall. The kyphosis in the disc space indicates the disc is disrupted along the entire posterior annulus. This is not dissimilar to a soft tissue Chance fracture.
Successful brace treatment in my opinion would be improbable. It is well documented that these soft tissue injuries will not heal and instability will remain without surgical stabilization. The 32 degree kyphosis if not surgically reduced will cause a hyperextension compensation in the lower lumbar spine and increased loading of the lumbar facets. Future lower back problems could be predicted.
The surgical construct is brilliant. I am surprised that after four to six weeks post injury that the reduction looks as good as it does. The healing pannus in those six weeks normally can cause a block in surgical reduction. This construct is a tension band reduction and this patient should be able to return to full activities with minimal residuals after full fusion occurs. I typically place these patients in an extension TLSO after surgery for three months.